Mental Health and Well-Being Among Home Health Aides

Key Points Question What are home health aides’ and attendants’ (HHAs’) perspectives toward mental health and well-being, and how does their job influence them? Findings In this qualitative study of 28 HHAs employed by 14 different home care agencies, participants reported various personal and occupational factors that affected their mental health and well-being, particularly their relationships with patients. While the participants used multiple strategies to cope, they were eager for support to help manage mood and stress on the job. Meaning These findings suggest that interventions and policies geared toward mental health are needed to better support HHAs as they provide essential patient care.


Introduction
Most older adults prefer to stay in their homes as they age and to avoid nursing homes, a concept known as aging in place. 1 To age in place, many individuals require help at home.While this help is often provided by family caregivers, home health aides and attendants (HHAs) are increasingly providing assistance. 2,3These HHAs are a rapidly growing workforce trained and certified to provide personal and medical care, as well as emotional support, in the home. 3Unlike other health professionals, HHAs are with patients in the home for long periods, which gives them a unique vantage point to observe, support, and advise patients.
Despite their contributions to patient care, recent studies have found that HHAs themselves are a vulnerable workforce susceptible to poor mental health. 4,5Much of this susceptibility may partly stem from HHAs' marginalized positioning in the health care industry and historically poor labor protections as a workforce. 6,7Additionally, HHAs, who are mostly women and people from minoritized racial and ethnic groups, are paid dismally low wages, and 26% lack health insurance, which inhibits their access to quality mental health care. 8The COVID-19 pandemic worsened HHAs' working conditions and their physical and mental health. 9,10Home health aides and attendants, who often work alone without coworkers, provided care during the COVID-19 pandemic without the personal protective equipment and other basic supports that institutionally based workers received (eg, paid sick leave and access to testing). 9,10This resulted in many living with fear of contracting and transmitting COVID-19. 9A survey of agency-employed HHAs in New York City found that two-thirds were struggling to manage their mental health post pandemic. 11Overall, since COVID-19, 70% of HHAs wanted more support to cope with stress, anxiety, and mood. 12Left untreated, HHAs' poor mental health may threaten not only their well-being but also their ability to provide highquality patient care.
While prior studies have quantified the prevalence of HHAs' poor mental health, 4 the unique workplace stressors in the home environment during COVID-19, and their desire for support, there has been little investigation with HHAs themselves about what factors influence their perceptions of mental health and how their job contributes, particularly in the post-COVID-19 era.Additionally, while a recent study elicited home care agency leaders' perspectives for how to address the workforce's deficits in mental health and well-being, 13 HHAs have rarely been asked to provide their own recommendations on potential solutions, a critical aspect of sustainable and effective intervention development.
Thus, we aimed to understand HHAs' attitudes toward mental health and well-being and how their job creates barriers and/or facilitators toward maintaining them.Additionally, we elicited HHAs' perspectives on what types of interventions could meet their emotional needs in the context of their job.
To ensure that we focused on HHAs most in need, we included those at risk for poor mental health and well-being as defined in the literature and with input from experts in long-term care.To be eligible for this study, HHAs (1) spoke English or Spanish; (2) were employed by a licensed or certified home care agency in New York City; and (3) had 1 or more risk factors for poor mental health and well-being assessed across 3 domains, including depressive symptoms, stress, and loneliness.
Depressive symptoms were assessed with the 8-item Personal Health Questionnaire depression scale 17 ; a score of 5 or higher on a scale from 0 to 24 was considered positive for mild depressive symptoms. 18,19Stress was assessed using the 4-item Cohen Perceived Stress Scale 20 ; a score of 6 or higher on a scale of 0 to 16 was considered positive for moderate or greater stress symptoms. 21neliness was assessed using the 3-item University of California, Los Angeles Loneliness Scale 22 ; a score of 6 or higher on a scale of 3 to 9 was considered positive for loneliness.23 These validated assessments were administered in English and Spanish.
Using a standardized recruitment script, 1199SEIU TEF staff reached out to affiliated HHAs who were in contact with the organization during the study period.If interested in participating, Weill Cornell Medicine research assistants (M.Y.H. and E.F.-C.K.) then sent an electronic screening survey via REDCap to HHAs to assess eligibility. 24,25If eligible, HHAs were scheduled for a languageconcordant virtual focus group conducted through videoconferencing.Due to scheduling constraints among HHAs (ie, patient shifts, commutes), interviews were used as a substitute form of data collection when needed.

Data Collection
Two researchers (M.Y.H. and E.F.-C.K.) trained in qualitative research methods moderated the 60-to 90-minute virtual focus groups and conducted the interviews using a semistructured topic guide.
The topic guide was informed by a previously published conceptual framework that combined aspects of Pender's Health Promotion Model and the National Institute for Occupational Safety and Health's Total Worker Health conceptual model (eFigure in Supplement 1). 5 The topic guide asked participants about their overall health and specifically about their attitudes toward mental health and well-being, including how their job influences their mood and stress levels.Participants were also asked about the challenges and facilitators that their work presents to their overall mental health and well-being, including the COVID-19 pandemic.
Additionally, they were asked about their preferences toward future interventions that could meet their needs (eAppendix in Supplement 1). 5,26,27In addition to the interviews and focus groups, selfreported demographic characteristics, including age, sex, race (including Asian, Black, White, and other [including Hispanic, Brown, or not specified]) and Hispanic or Latinx ethnicity, educational level, and employment history, were collected.Race and ethnicity are essential to include since HHAs are historically a minoritized population (mostly women and women of races and ethnicities other than White) of frontline health care workers; we wanted to ensure that we had diversity in race and ethnicity and by language spoken.

Data Analysis
Interviews and focus groups were conducted via videoconferencing, audio recorded, and transcribed professionally.Data were organized using a custom-built Python-based visualization tool, which has been previously used in other qualitative investigations. 9,280][31][32] First, 2 investigators (M.Y.H. and E.F.-C.K.) trained in qualitative coding independently reviewed 5 transcripts and created codes.The investigators met to reconcile and consolidate their codes to create an initial codebook with oversight by a third investigator (Y.H.T.) and a senior investigator (M.R.S.).The codebook was then applied to the remaining transcripts, pausing at every fifth transcript to review, reconcile, and consolidate as a team.The codes were categorized into themes and subthemes by the investigative team.Focus groups and interviews concluded when data saturation, the point at which no new themes emerged, was reached. 33We examined data across focus groups and interviews to assess for differences in results from these 2 interview modalities but found the data to be thematically consistent.Thus, data were merged and presented as 1 dataset regardless of data collection modality. 34,35Descriptive statistics were performed to characterize the sample.We performed the data analyses using Stata/MP, version 14 software (StataCorp LLC).

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Mental Health and Well-Being Among Home Health Aides

Major Themes
Overall, 5 major themes emerged.Themes and subthemes are outlined in Table 2 and are detailed below, along with illustrative quotes.

Theme 1: Influence of Personal and Cultural Factors on HHAs' Attitudes Toward Mental Health and Well-Being
The participants' attitudes toward mental health and well-being were notably influenced by cultural and personal factors.While some participants reported feeling comfortable with discussing their mood, others reported stigma around mental health, which made it challenging.One participant said that "a person mentions something about mental health, then it crosses your mind that this person may…have mental problems.The first thing you think is, 'they're crazy'.…Itmakes you feel ashamed or afraid." In general, personal responsibilities outside of work, including family caregiving, affected their mood.As 1 participant explained, "I have personal stress that I'm going through with my young son, and sometimes it's emotional.I come to work, and I have to put that to the side and to do my job in a professional way.Sometimes it's hard." While participants talked about caring for others, they also reported needing to manage their own medical conditions, including diabetes and hypertension, which added to their stress.One participant explained, "I have diabetes, and I worry a lot about it-what I eat, how much I exercise, my weight.…"

Theme 2: Influence of Relationships With Patients on HHAs' Mood
Participants reported that their relationships with patients affected their mood in both positive and negative ways.Certain situations were particularly challenging, including caring for patients who

No. of symptoms in participants
Depressive symptoms were assessed using the 8-item Personal Health Questionnaire depression scale, for which scores of 5 or higher on a scale of 0-24 are considered positive for depressive symptoms. 17Stress was assessed using the 4-item Cohen Perceived Stress Scale, with scores of 6 or higher on a scale of 0-16 indicating more perceived stress. 21Isolation was assessed using the 3-item University of California, Los Angeles Loneliness Scale, with scores of 6 or higher on a scale of 3-9 indicating loneliness. 22equire additional services beyond the agency's plan of care (ie, housekeeping or extended hours) or caring for those with complex or emotionally taxing illnesses (dementia, depression, etc).One participant recounted, "Well, with the job, of course you're working with [patients]…they have their little mood and their little attitude and tend to get you….I try to be always with a smile, even though it hurts me." Another participant described that at times, patients could be racist toward them, which presented a problem since they are in the home alone with the patient for long periods.One participant said, "Some [patients] are racists, and they look at you as if you are less than them, but I don't pay that any mind.I do my job and if it ends up being hard, well, I tell them to find me another." Patients' family members could also be problematic.Additionally, participants highlighted several issues pertaining to their home care agencies, including poor communication and insufficient information regarding their patients, that contributed to stress on the job.For example, some participants mentioned not being told about their patients' health issues both prior to and during home care episodes, often having to rely on family members to obtain relevant details.As 1 participant explained, "Some of the clients…don't even know what is their health problem.They just hire us and send us out on these cases.They don't know…somebody's family members don't even discuss it."Participants reported using a range of strategies and health behaviors to manage their emotions and mood both off and on the job.When asked how they cope, many discussed doing breathing exercises and meditation, engaging in prayer, and physical activity.As 1 participant explained, "The first thing I do is pray to God to give me strength to move forward because the struggle here has not been easy." Additional strategies that participants reported using included listening to music, watching TV, playing games, reading, and taking courses.One participant said, "Sometimes I try to hide it, but I do cry.But then afterwards, I try to calm down a bit, I don't know, sometimes I play music.I entertain my mind." Beyond these activities, many participants compartmentalized difficult work situations to help get through the day.As 1 participant explained, "I try not to make my emotions get to my job….I'm there to take care of her.I do what I got to do then…deal with whatever I got to deal with later."Some participants did not just compartmentalize patient dynamics but also tried to leave stress from their personal lives, including family caregiving responsibilities, at home during their shift.
Notably, although many participants reported that the job contributed to stress, some perceived their work as a means of escaping from problems at home.They expressed a sense of anticipation for their work schedule since this could help them cope with their experiences at home.As 1 participant remarked, "When I'm working, I'm in a good mood.This is my escape."

Theme 5: Eagerness for Interventions That Can Improve Their Mood
Many participants wanted programs and supports that could improve their mood and feelings on and off the job.One participant explained, "I wish I could participate in a program that could make me feel good, I mean, that could help me." Participants reported that this type of information would benefit their health and their patients.
Many suggested that courses on mental health, or wellness in general, from their union or their home care agencies would be beneficial.One participant said, "I really like to learn…you can share that [knowledge] with other people too." Participants also wanted to learn from each other.They reported that peer coaching, which they have experienced before, could be a potential solution, particularly for mental health where stigma and occupational stressors may be influential.They appreciated how it offers a way to talk with fellow HHAs who had similar job-related challenges and learn from and support each other in a nonjudgmental way.One participant stated, "It is always good to share different opinions with someone who knows your situation.And to work together too." The need for on-the-job support from other HHAs was also driven, in part, by participants' expressed difficulty in discussing their professional experiences with their families.The reasons they cited were concerns about patient privacy or their preference to keep work and family life separate.

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Mental Health and Well-Being Among Home Health Aides

Theme 3 :
As 1 participant explained, "They live with family, and there are some that are hateful.What you do is to try to focus on your work and not pay them much attention…and it is bad to arrive at a house where you feel uncomfortable."Counter to the negatives, other participants reported a deep sense of gratification and joy from their work.They discussed how forging meaningful relationships with their patients made them feel good.Many participants reported taking pride in their work, often driven by their desire to make a positive difference in the lives of their patients.When speaking about her work, 1 participant stated, "I love working in the health care field.I love taking care of people.I love people to be happy.I love to give all what I have to them, try to do my best."Influence of Structural and Organizational Aspects of the Job and COVID-19 on HHAs'Mood and Stress LevelsSeveral participants described how the structural and organizational aspects of their job, alongside the COVID-19 pandemic, contributed to their stress levels.Many described that working extended hours, having long commutes, and receiving inadequate compensation substantially impacted their well-being.As 1 participant explained, "[The] cost [of living] is very high right now….Nobody can live with $17 no more in New York.This is another stress."Many participants also reported having insufficient time for themselves, including taking breaks or even having lunch, which compounded the strain.

Table 1 .
Sample Characteristics Discrimination in the workplace was measured by the National Institute of Occupational Safety and Health Well-Being Questionnaire.An answer of yes to any of the 4 questions indicated discrimination in the workplace.
a Participants who selected other race identified as Hispanic or Brown or did not specify.b Overall experience in the workplace was measured by the Work Domain c d Social support was measured by the Multidimensional Scale of Perceived Social Support.Total scores range from 7 to 84, with higher scores indicating a greater degree of perceived social support.e A score of 42 or less may be indicative of clinical depression.f A score of 50 or less is the recommended cutoff for determining a physical condition.

Table 2 .
Themes and SubthemesDownloaded from jamanetwork.comby guest on 06/08/2024 Furthermore, participants reported that lack of explicit guidelines and information from the agency to the client regarding how to respect HHA boundaries created challenges.A participant recounted, "it's a lot of challenges being a home attendant.If God bless you, you have good clients that treat you like your own, you're blessed.A lot of people treat home attendants as a domestic staff.